GFF COUNTRY WORKSHOP 2017

APRIL 18-19, 2017, Washington DC

1

GFF Country Learning Workshop Report

The GFF Country Learning Workshop was organized on 18-19 April 2017 to respond to the evolving learning needs of GFF practitioners to draw lessons from experiences and enable course corrections for implementation. The workshop was held in Washington D.C. to enable participants to benefit from attending the Universal Health Coverage (UHC) Forum, held on 20-21 April 2017, focusing on efficiency.

1. Workshop Participation The GFF Country Learning Workshop brought 16 GFF-supported countries1 together to elaborate on the GFF’s vision, discuss experiences, identify challenges and share lessons learned. Each of the 16 country teams was invited to nominate seven members. On the government side, participants included the RMNCAH coordinator from the Ministry of Health (MOH), a health financing expert from the MOH, and a representative from the Ministry of Finance (MOF). Further, country teams included a financier of the Investment Case, a technical partner and/or a representative from a civil society organization. On the World Bank side, each country team comprised the World Bank Task Team Leader and the health financing focal point. In total, more than 150 people participated in the GFF Country Learning.

2. Workshop Methodology The GFF Country Learning Workshop was designed through consultations to support the design, monitoring and implementation of GFF-supported Investment Cases and health financing strategies. With countries increasingly shifting from design to implementation, the workshop also focused on exploring the best ways to operationalize the GFF at country level, including through learning from implementation modalities. Workshop content also specifically focused on sharing health financing policy and implementation experiences to help GFF-supported countries seize the opportunity presented by the Universal Health Coverage (UHC) Forum held on 20-21 April 2017 in Washington D.C., focusing on efficiency.

1 Participating countries included Bangladesh, Cameroon, Democratic Republic of Congo, Ethiopia, Guatemala, Guinea, Kenya, Liberia, Mozambique, Myanmar, Nigeria, Senegal, Sierra Leone, Tanzania, Uganda and Vietnam.

2

To maximize learning, the GFF Country Learning Workshop adopted a methodology that encourages knowledge sharing and peer-to-peer discussions. Informed by feedback provided after the first Country Learning Workshop held in Kenya in 2015, it adopted an approach that combined plenary sessions with sharing country experiences and country group sessions to discuss and promote exchanges on specific topics, such as health financing, and identify next steps to move the agenda forward.

3. Workshop Content Introduction to the GFF and Lessons Learned This session introduced the GFF vision and its intended results. It highlighted the added value of the GFF partnership and clarified the role of the GFF Secretariat in attaining RMNCAH+N results. It also showcased the way through which Liberia and Cameroon are leveraging the GFF to accelerate GFF results, highlighting challenges faced, lessons learned and the next steps to be taken. Icebreaker: main challenges This icebreaking exercise required participants to survey other country team members to determine the challenges faced by individual countries when implementing the GFF approach. Encouraging peer-to-peer exchanges, it helped highlight the most prominent challenges faced, namely: 1. Limited accountability of funders and/or implementers; 2. Inefficient use of financing; and 3. Limited technical and/or managerial capacity to implement. Moving from Design to Implementation With GFF-supported countries increasingly moving from design to implementation, this session detailed the five core principles guiding the operationalization of the GFF at country level. These principles include: 1. A Relentless focus on Results; 2. The use and building of evidence to achieve results; 3. The creation of a multidimensional response; 4. A continuous and adaptive implementation with rapid feedback loop; and 5. Leadership for change

Implementing the GFF: Financing Systems for RMNCAH priorities This plenary session specifically highlighted the ways through which continuous financing could be promoted in the short term to address a country’s RMNCAH+N priorities. It also underlined long-term financing issues related to improving efficiency and increasing the availability of domestic resources. This session was coupled with a focused group session where individual country teams discussed the policies and actions required in their respective countries to stimulate progress in the short-term as well as in the long-term. This included a reflection on how to mobilize and align domestic and external financing, and how to spur other efficiency gains. From Design to Implementation: Achieving Results for Women, Adolescents and Children This plenary session drew on country experiences to stress the importance of governance and accountability systems in ensuring joint and rapid implementation. It also elaborated on the ways in which a rigorous data-driven monitoring and learning approach can be operationalized, building on the views and experiences of several GFF countries. To help further reflection on implementation in specific contexts, this session was supplemented by a group session during which country teams focused on identifying a priority guiding principle, discussing potential challenges and considering next steps.

3

4. Country Reflections: Summarized Highlights

a. Financing Systems for RMNCAH priorities

Bangladesh focused on further engaging the private sector to improve domestic resource mobilization, particularly exploring ways to increase corporate social responsibility investments for health and enhanced private health service delivery. Identifying a lack of information on private sector activities, poor quality of private service delivery and a weak regulatory framework as key challenges, the country team decided to concentrate future activities on the establishment of a policy dialogue with the private sector; on the strengthening of the regulatory framework; the creation of new contracting arrangements, including incentives; and the improvement of information exchanges and collaboration.

Cameroon discussed the need to develop the health financing strategy and the UHC strategy in a harmonized manner, as health financing is an integral part of UHC strategy. To create such synergy, the Cameroonian team agreed to link the costing of the benefit package carried out by the UHC working group with the fiscal space analysis led by the health financing group. They also decided to consider a cost containment policy for the Health Financing Strategy to avoid a costly reform and facilitate implementation.

The Democratic Republic of Congo (DRC) explored how to improve public financial management to maximize implementation. The country team explored weaknesses inherent to budget and planning processes as well as inefficiencies linked to budget execution. To overcome identified challenges, it decided to focus on increased dialogue with government stakeholders at all levels, including decentralized levels, and on establishing additional surveillance and control mechanism to ensure the appropriate use of funds.

Ethiopia expanded on key challenges to improved domestic resource mobilization. The country team identified the weakness of the financial information system, the lack of a private sector engagement strategy, as well as limited capacity to use existing evidence for decision making as major impediments. It also discussed ways to improve service delivery in less performing areas, considering issues pertaining to the distribution of human resources, existing inefficiencies and contextual factors. As next steps, the country team proposed focusing on the establishment of a new health insurance system; strengthening health facility revenue retention and utilization; increasing private sector engagement and increasing general government expenditure for health (i.e. from six to ten percent).

Guatemala discussed the steps required to develop a health financing strategy with domestic resource mobilization modalities tailored to the Guatemalan context. Underlying the need to strengthen both operational and policy levels, the country team’s plan of action includes mapping resources; exploring new purchasing and domestic resource mobilization modalities; reforming the social security system; and strengthening the capacities and leadership of the public sector.

Guinea concentrated on key barriers hampering the implementation of Investment Case priorities, particularly focusing on improved public financial management. These barriers include (1) inadequate health facility financing, with health facilities depending on their own revenue to cover costs; and (2) the lack of correlation between funding and operational needs, creating a disconnect and limiting service delivery.

Kenya considered the efficient use of resources for health at both national and county levels. The country team highlighted key challenges, including the lack of county-level information on the availability and use of resources for health; the lack of synthesis on the key causes of inefficiency; and the lack of understanding of the causes of inefficiency inherent to the public financial management structure. Based on these challenges, the country team proposed to direct efforts toward mapping of resources at county level; piloting and rolling-out the standard resource mapping tool used by the MOH; synthesizing existing studies

4

on the major causes of inefficiency and conducting county case studies; and carrying out a detailed analysis of the public financial management structure, using health as a case study.

Mozambique explored barriers to improved revenue raising and utilization in the health sector, keeping an eye on the financial burden shouldered by the poor. The country team specifically highlighted the need to address the lack of mechanism to target patients across economic strata to provide additional protection to the poor; the inadequate financing of human resources for health; and the poor quality of care. To do so, the team plans to assess how health insurance premiums paid by civil servants are reinvested into service delivery; explore the design and implementation of a health insurance for all; include sin taxes on tobacco and alcohol and other commodities to mobilize additional domestic resources; and include performance-based incentives to drive improvements in the quality of care.

As Myanmar is planning to develop a health financing strategy for its 2017-2020 National Health Plan, the country team focused on developing an action plan to: (i) analyze the fiscal space to identify ways to increase government spending for health; (ii) define and cost an explicit benefits package; (iii) explore ways to strengthen pooling and prepayment – for instance, considering whether the national social security scheme should be linked to the current social security scheme for formal sector employees or whether it should take a contributory approach; and (iv) improve purchasing arrangements by implementing a purchaser-provider split, initially through an international Non-Governmental Organization (NGO) based in Yangon and subsequently through the establishment of a semi-autonomous agency.

Nigeria explored the added value provided by the GFF, particularly highlighting its contribution in innovation in the private sector. The country team also discussed health financing and recommended creating a technical committee led by the MOF and dedicated to work on the allocation and tracking of health resources within the MOH. It also proposed to focus on costing the Investment Case, including the basic package of services.

Senegal looked at issues pertaining to fragmented funding; poor resource tracking and the inefficient coordination between central and regional levels. The country team considered introducing a resource tracking software/tool to allow partners to enter their resource contributions in real-time, and facilitate resource planning at the government level. It also suggested exploring the applicability of the Congolese “contrat unique” to improve harmonization and coordination with all stakeholders, including with NGOs

Sierra Leone discussed how to improve the efficiency of resource utilization, particularly exploring the lack of partner/donor coordination and transparency at national and sub-national levels; the lack of accountability; as well as inefficient health financing and poor quality of health. As next steps, the country team proposed strengthening domestic resource mobilization; reinforcing Service Level Agreements with partners; exploring collaborative supervision including the MOH and MOF to promote better alignment between funding and operational needs; and the introduction of financial and non-financial incentives to improve health worker geographic distribution and performance.

Tanzania considered the current limitations inherent to the fiscal space, encumbering additional revenue raising and domestic resource mobilization. To overcome these limitation, the country team proposed an action plan including additional efficiency-related measures to identify gaps in domestic financing. It also advocated for additional attention to be given to innovative private sector engagement modalities, and effective financing mechanisms to protect the poor from catastrophic health spending and ensure access to health services including RMNCAH services when needed. The country team also stressed the need for more analytics to inform health financing policy-making and implementation.

Vietnam explored ways to expand health services delivery to reach ethnic minorities, especially women, in remote and/or disadvantaged districts to reduce maternal and neonatal care. The country team also discussed ways to improve financing for the prevention of maternal to child transmission of HIV (PMTCT).

5

Discussions particularly covered challenges, including the lack of qualified village births attendants; the lack of sustainable financing to cover human resources for antenatal care, skilled deliveries and newborn care (neither reimbursed by the health insurance fund nor by the government, which only covers material costs); and the lack of consistency in the provision and financing of PMTCT services.

b. Guiding Principles for Implementation

Bangladesh discussed the need to further engage and convince the Ministry of Health and Family Welfare (MOHFW) to use data to guide resource allocation-related decisions. The country team stressed the need to instigate public financial management reform and to improve budget allocation, notably for the implementation of social health protection schemes. It also underlined the need to involve the private sector in providing services in remote and neglected areas. The country team recommended further engaging the MOHFW and the MOF into a policy dialogue; generating evidence to reform the public financial management system; exploring social health protection schemes; and developing a platform to mobilize the private sector for health.

Cameroon focused on the creation of a multidimensional response, particularly exploring how best to align all stakeholders for the operationalization of the GFF. The country team particularly stressed the need to shift the focus from the functionalities of the country platform to its specific role and objectives. To do so, the country team proposed creating results-oriented terms of reference. It also advocated for the creation of regional platforms with similar terms of references to ensure alignment at all levels. To further align partners, the country team recommended (i) mapping partner activities regularly (i.e. at least annually) to avoid overlaps and reduce gaps; (ii) organizing quarterly coordination meetings; and (iii) ensuring regular monitoring to track progress and make timely course corrections, when necessary.

The Democratic Republic of Congo (DRC) concentrated on the use and building of evidence to achieve results, particularly focusing on the weaknesses of available data systems and tools. Notably, the country team discussed the fragmented nature of data systems; the unavailability of data collection tools at local level; and the inappropriate use of technologies – whereby considerable investments are directed toward satellite systems despite smartphones being more cost effective. Further, the country team discussed the need to provide better access to data as Health Management Information System (HMIS) data is currently “sequestered” and inaccessible.

As a result of this discussion, the country team recommended focusing on capacity building to stress the importance of quality data and train human resources for health, particularly at facility level, in the collection and use of evidence. It also proposed decentralizing data analysis at provincial and facility levels to better inform decision making and planning. The country team also suggested placing the HMIS under a new authority to facilitate data access and ensure accountabilities. Regularly publishing peer reviewed articles and attending conferences were also mentioned as potential ways to further encourage the use of health data – as was the case in Rwanda.

The country team also explored the principle of leadership for change, underlying the passivity of provincial level and miscommunication between central and local levels; and the lack of information from partners as barriers to change. To address these barriers and facilitate required change, the country team recommended identifying champions of change at provincial level to help initiate discussions on how to raise revenue for health, better allocate resources (i.e. both financial and human), and better incentivize health workers in remote areas. It also proposed exploring ways to improve ownership of the ‘contrat unique’.

As Guatemala was at the initial stages of the GFF process, the country team reflected on the added value of the GFF in Guatemala. It particularly highlighted the opportunity presented for increased transparency within the government; improved and aligned private sector engagement; and enhanced coordination and

6

collaboration between the MOH and the MOF, particularly in the development of a health financing strategy.

Guinea discussed the use and building of evidence to achieve results. The country team highlighted key challenges, such as the lack of human and financial resources to conduct data-related activities and the lack of capacity to analyze data in a way that is relevant for decision-making. Conversely, it stressed the need to determine a clear approach to use relevant data for decision making and planning processes, and to increase the production of relevant information.

Ethiopia concentrated on strengthening its multidimensional response to further focus on results. The country team discussed how various technical working groups feed into the Joint Core Coordinating Committee (JCCC) and the Joint Consultative Forum (JCF) – which serve as the country platform to coordinate multiple stakeholders. This discussion underlined that earmarked funds and external financing are off-budget and, thus, unpredictable and difficult to track. It also highlighted inefficiencies at decentralized levels as local/woreda and regional platforms are seldom functional. In this light, the country team advocated for all financing to be on-budget. It further recommended strengthening accountabilities through (i) the organization of regular meetings; and (ii) a shared strategic agenda developed in a participatory manner. It also stressed the need to organize annual consultations at the sub-national level and to facilitate exchanges between government organizations and NGOs. These consultations and exchanges could help develop a common annual plan endorsed by all partners, containing all indicators to be tracked and monitored.

Kenya explored key barriers to a multidimensional response, highlighting the need to get the right level of political leadership and to anchor the country platform within the country partnership framework. The country team recommended forming a country platform with high level representation. At national level, it proposed a country platform led by the Director of Medical Services. At county level, it suggested engaging governors to lead county platforms and the implementation of county operational plans.

The country team also addressed domestic resource mobilization, advocating for improvements in public finance management to respond to the funds flow issues. It also discussed the importance of evidence in achieving results, and suggested combining data sources and improving community accountability systems. In this context, the country team recommended further exploring the approaches adopted by Bangladesh and Ethiopia.

Liberia discussed two priority guiding principles, namely the relentless focus on RMNCAH results and the use and building of evidence to achieve results. The country team particularly highlighted the need for the MOH and the Ministry of Finance and Development Planning (MFDP) to work together to map resources, identify gaps, and monitor progress. It recommended the MOH provide regular updates on health system performance to the MFDP; the integration of the Health Financing Unit (HFU) and the Family Health Division into the Health Financing technical working group; and the joint tracking of health expenditures – led by the HFU with the support of the MFDP.

Mozambique considered adolescent education and health indicators to showcase the need to harmonize results frameworks/indicators across sectors. The country team also discussed increasing the frequency of progress reviews to identify “poor” performers and provide appropriate timely supervision support. To facilitate such alignment and ensure appropriate monitoring, the country team recommended (i) finalizing the Adolescent Health Strategy, and (ii) using the existing multi-sectoral platform – including the Ministry of Health, as well as the Ministries of Education & Human Development, Youth & Sports and Gender, Child and Social Welfare and Ministry of Justice, development partners and civil society – to track implementation.

7

Senegal identified the improvement of the country platform as its first implementation related priority. Working under the supervision of a technical committee chaired by the Minister of Health, the country platform validates the GFF Investment Case. The country platform is however experiencing difficulties in fulfilling its role as it comprises a large number of uncoordinated stakeholders. This is exemplified by civil society participation which inconsistent and, at times, rooted in competition rather than collaboration. To improve the country platform, the country team proposed (i) establishing clear participation guidelines (i.e. two delegates per organization, one main representative and one substitute) to ensure consistency; (ii) consult with stakeholder constituencies (e.g. private sector, civil society) to help them define common objectives and elect representatives; (iii) ensuring access to meeting minutes; and (iv) defining a clear timeline with specific next steps forthcoming meetings.

Sierra Leone prioritized focusing on RMNCAH Results, including the use and building of evidence to achieve results. The country team discussed how to improve the financial and technical accountability of local councils, particularly exploring using the RMNCAH scorecard and building on the HMIS Strategic Plan. It recommended carrying out joint supervision visits involving the Ministry of Finance and Economic Development and the MOH. These visits could help rank councils based on pre-defined financial and technical criteria, and produce a public report disaggregating results by district. These results could then be used to set annual targets for each district based their specific context. Districts would regular report on progress using a limited number of indicators – simplicity should be key. The team also stressed the need to explore how to publicize the RMNCAH scorecard, integrate it into decision-making at national and council levels, and identify target audiences.

Tanzania considered the use and building of evidence to achieve results. The country team reflected on existing challenges, including increasing pressure placed on providers to collect information, limited capacity to prepare dashboards, partner reluctance to share data, insufficient resources and lack of synchronization between data systems. Based on this reflection, the country team underlined the need to (i) identify core indicators to guide reporting at all levels; (ii) use the existing SWAp platform to generate agreement and ensure stakeholder alignment; (iii) map partner service provision and ensure prioritization of the One Plan II; and (iv) link the public financial management information system to the service delivery information system.

Vietnam concentrated on the lack of qualified human resources and on the inadequacy of their remuneration, particularly to incentivize work in remote and poor areas. In the absence of a clear policy, localities seldom allocate funds to underserved areas. To improve the number, distribution and remuneration of human resources for health, the country team recommended conducting a rapid situation assessment of RMNCAH human and material resources, particularly in disadvantaged districts. It also proposed carrying out a resource mapping to identify gaps and help prioritize future activities. Finally, it recommended assigning obstetric-pediatric staff to the commune level to help build capacity at the local level and/or provide CME training to upgrade skills.

8

5. Country Learning Workshop Participant Survey

At the end of the second GFF Country Learning Workshop, participants were asked to provide feedback on the relevance and quality of the workshop. Using a questionnaire with a Likert-like scale ranking participants’ satisfaction from one (i.e. “very dissatisfied”) to five (i.e. “very satisfied”), this survey sought to determine the relevance and quality of the workshop’s methodology and content. Overall satisfaction: quantitative results The overall response rate is 59 percent, representing 75 respondents on 127 participants, excluding faculty members. The total average score is four, suggesting that workshop sessions have been effective in transferring knowledge and in providing guidance to country teams at different stages of the GFF process (c.f. Table 2).

Table 2: Average scores

These positive learning outcomes are further highlighted by the frequency distributions of each criterion, which further indicate that participants were predominantly either very satisfied or satisfied (c.f. Table 3). Survey findings show that workshop content was relevant or very relevant for 86 percent of participants. This is emphasized by respondents qualifying the workshop as “a good opportunity to share and learn” and expressing their satisfaction by saying “good job!” and ““keep going! Bravo!”. This terminology further suggests that workshop content was considered relevant as well as useful. However, although 54 percent of respondents indicated being satisfied or very satisfied with the novelty of the information acquired, 37 percent provided a neutral answer. In this regard, one participant, for instance, stated: “presentations keep on being the same…I am more interested in exploring specific country experiences, challenges and lessons learned”. This underlines the need to ensure information is new for all participating stakeholders at all stages of the GFF process.

Table 3: Frequency distributions of criteria evaluated

Criteria Very

Satisfied (%)

Satisfied (%)

Neutral (%)

Dis-satisfied

(%)

Very Dis-satisfied

(%)

No response

(%)

Relevance for GFF operationalization in your country

43 43 8 3 0 4

Extent to which information acquired is new

12 42 37 8 0 1

Applicability of the information acquired 24 55 19 1 0 1

Extent to which workshop content matched announced objectives

39 49 8 1 1 1

Usefulness of group work and country exchanges in advancing GFF Implementation

52 33 8 4 0 1

Extent to which teaching methods used were stimulating

21 41 25 7 0 5

Average scores

Relevance New

Information Applicability: Information

Content vs.

Objectives

Usefulness: Group Work

Teaching Methods

Total Average

Score

4.31 3.58 4.03 4.24 4.37 3.79 4

9

Survey findings also underline that 62 percent of participants viewed selected teaching methods as either stimulating or very stimulating, while 25 percent felt impartially and 7 percent felt unstimulated. Some qualitative comments point to the need to shorten plenary sessions and focus on more participatory teaching methods. This is further confirmed by the wide appreciation expressed for country group activities, which benefited from a satisfaction rate of 85 percent. As stated by one respondent, “We do not often have the time and space to discuss and share experiences. We thus welcome opportunities to learn from each other, be it within our country team, across sectors, or with other GFF country teams”. Recommendations Participants also shared some recommendations for future workshops and/or GFF seminars, thereby helping to further tailor content and methodology to the evolving needs of GFF practitioners. These recommendations advocate for more in-depth discussions on specific topics. These topics are listed in Table 4.

Table 4: Recommended Topics for In-Depth Discussions

Health Financing e.g. purchasing, etc.

Link between RMNCAH, health financing and Universal Health Coverage

Data/Accountability

Monitoring and Evaluation, accountability and community participation

Resource tracking and allocation

Civil registration and vital statistics (CRVS)

Health management information system (HMIS)

Integration of CRVS and HMIS

Operational data and decision making

Data quality

Governance

Roles of different actors in the operationalization of GFF

Country platform management

Multi-sectoral collaboration

Effective GFF coordination mechanisms at country level (i.e. what has worked and what has not worked)

Clinical

Lessons from countries with a similar profile and how they managed to reduce maternal mortality

Approaches to improve nutrition

Quality assurance

10

6. Annex 1: Agenda GFF Country Learning Workshop

Agenda – Day 2: Wednesday 19th of April

7:00am Breakfast

8:30-9:00am Recap from Day 1

9:00-10:30am Improving GFF Implementation to Achieve Results for Women, Adolescents and Children

10:30-11:00am Coffee/Tea break

11:00-12:30pm Country group work: Improving GFF Implementation to Achieve Results for Women, Adolescents and Children

12:30-1:30pm

Lunch break

parallel 1: discussion on GFF IG governance with select participants parallel 2: discussion on country platform guidance note with interested participants

1:30-3:00pm

Further learning on technical topics to support GFF implementation

This session will consist of parallel sessions of topic of interest to the countries:

- Sexual Reproductive Health and Rights

- Buy Downs (for Guatemala and Vietnam)

- Private Sector and Innovations

- Other parallel sessions (TBD)

3:00-3:30pm Coffee/Tea break

3:30-5:00pm Country feedback: next steps and learning

Agenda – Day 1: Tuesday 18th of April

7:00am Breakfast

8:00-8:30am Registration

8:30-9:00am Opening and introduction

9:00-10:30am Introduction to the GFF and lessons learned

10:30-11:00am Coffee/Tea break

11:00-12:00pm Icebreaker exercise

12:00-12:30pm Moving from GFF Design to Implementation

12:30-1:30pm Lunch break

(parallel: CSO-led consultation meeting)

1:30 -3:00pm Implementing the GFF: ensuring that financing systems work to achieve results for women, adolescents and children

3:00-3:30pm Coffee/Tea break

3:30-5:00pm Country group work: ensuring financing systems work for RMNCAH priorities

6:00pm – 8:00pm Group Dinner.

11